The aim of this review was to examine the literature on the effects of surgery of the spastic hand in children with cerebral palsy on functional outcome and muscle coordination. We performed a search of the relevant literature in Medline, Embase, and Biological Abstracts from 1966 to June 2006. The search resulted in eight studies on the effect of surgery on functional outcome and three studies on the effect of surgery on muscle coordination. Heterogeneity in outcome measures precluded meta-analysis. The studies revealed that -at the level of impairment -surgery has a positive effect on supination and dorsiflexion of the wrist. At the level of function, surgery might improve grip strategy and induce an increase of the repertoire of grips and spontaneous use of the hand. The evidence for the functional effects is, however, limited. Whether the possibly improved function is mediated by alterations in muscle coordination patterns remains unclear. The muscle coordination studies provided inconclusive results. We concluded that surgery improves the position of the hand and there are indications that it might improve hand function. Future research should address the question: does surgery improve hand function and, if so, is this due solely to a better hand position or does change in muscle coordination play an additional role?Cerebral palsy (CP) describes a group of disorders of the development of movement and posture, causing activity limitation that is attributed to non-progressive disturbances which occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behaviour, and/or by a seizure disorder. 1 Impaired arm and hand function are major problems of children with CP, which contribute to disability in daily functioning. Pathophysiological mechanisms which play a role in these problems are paresis of specific muscles and spasticity and/or reduced muscle length associated with spasticity and disuse. Imbalance between agonistic and antagonistic muscles influences the position of the arm and hand. Secondary contractures and joint deformities often result in adduction and inward rotation of the upper arm, flexion of the elbow, pronation of the forearm, flexion of wrist and fingers, and thumb-in-palm deformity. These impairments contribute to the difficulties experienced in reaching, pointing, grasping, releasing, and manipulating objects. The abnormal hand posture influences the ability for refined grasping of objects of different orientation or shape. 2 One of the treatment options in children with CP is surgery. Surgical treatment, which may include release of spastic muscles and tendon transfers, focuses on improving muscle

SIR-Our recent review on the effect of surgery of the spastic hand of children with cerebral palsy (CP) indicated that only studies with a low level of evidence were available, i.e. series of cases.1 The existing information indicated that surgery seems to have a positive effect on supination and dorsiflexion of the wrist, may improve grip strategy, and may induce an increase of the repertoire of grips and spontaneous use of the hand. The effect of surgery of the spastic hand on muscle coordination had only been addressed by three studies in a relatively systematic way. 2-4 Unfortunately, it remained unclear, whether the putatively better hand function was the result of a better positioning of the hand and fingers and ⁄ or changes in muscle coordination induced by tendon transfer. Therefore, we started a pilot study in order to obtain insight into changes in muscle coordination and quality of reaching movements after surgical muscle transfers of the upper extremity in adolescents with unilateral CP. We hypothesised that surgery would result in more coordinated and more efficient muscle recruitment, i.e. in lower muscle activation rates, a reduction in recruitment of all arm muscles in concert, and in a temporal coordination which more closely resembles that of typically developing adolescents.4-7 In addition we evaluated whether surgery would result in qualitative improvement of motor behaviour during reaching. Three adolescents with unilateral CP who had surgery for their spastic hand to improve grip strategy and functional use of the paretic hand were studied. Hand posture, movement quality, and muscle coordination during a simple reaching task were assessed preoperatively and three times during the first postoperative year.